A medical record, health record or medical chart is a systematic documentation of a subject's (human patient or animal) medical history and care. A medical record includes both a physical folder for each individual patient and contains the body of information that comprises the total of each patient's health history. Medical history of a subject is gained by a physician or other healthcare professional by recording physical data or by asking specific questions, either of the patient or of other people who know the patient and can give suitable information, with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient.
Medical histories vary in their depth and focus. For example, ambulance paramedics may typically limit their history to important details such as name, history of presenting complaint, allergies etc. In contrast, a psychiatric history can be lengthy and in depth since many details about a patient's life are relevant to formulating a management plan for a psychiatric illness.
Information in a medical record is necessary to provide continuity of care so that all appropriate health care providers have access to the health history. The medical record also serves as a basis for planning patient care, to document communication between health care providers, to assist in protecting legal interests, and to document care and services provided to the subject.
Traditionally, medical records have been written on paper and kept in folders. The folders are typically divided into useful sections, with new information added to each section chronologically as the patient experiences new medical issues. Active records are usually housed at the clinical site, but older records (e.g., those of the deceased) are often kept in separate facilities.
The advent of electronic medical records (EMR) has changed some of the format of medical records, but mainly has increased accessibility of files. Even so, existing formats for viewing medical records can lack the ability to view both current and historical data pertaining to a subject in a display readily accessible for diagnosing the subject.